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Instructions for completing the Workers' Compensation Employer's Quarterly Report

Instructions for completing the Workers' Compensation Employer's Quarterly Report. A sample of the form F212-055-000 is also available on the internet.

Report of Accident - Injured Worker Instructions - Spanish

This is a Spanish tranlation of the questions asked of the injured worker on the Report of Accident (ROA). This document also includes worker information translated into Spanish.

Affidavit of Wages Paid - Public Works Contract and Instructions

This form is a fillable Word document that is used by a contractor, company or agency to show the wages paid to employees on a public works project. The best way to use this document is to bookmark this page as a “Favorite” in your web browser. Then each time when you want to use the document, access the online version of the form. This will ensure you are always utilizing the most recently published form. (We recommend you not download the document and save the form for future use because we may make changes to the form that your downloaded version will not contain.) You must file the Affidavit of Wages Paid form when you have completed your portion of a public works job/project. Addendum A is form number F700-161-000, Addendum C is form number F700-162-000, and the EHB 2805 (RCW 39.04.370) Addendum is form number F700-164-000.

Prevailing Wage Complaint and Instructions

Ask L&I to conduct an investigation into a prevailing wage violation that affects one or more employees. See box 30 on the form to see what types of complaints are covered.


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Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers

Used by self-insured employers to report their quarterly statement of supplemental benefits. This form file now includes the instructions, which used to be a separate form number F207-011-111.

Provider's Initial Report (PIR)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.

Workers' Compensation Filing Information

Used by only self-insured employers to comply with WAC 296-15-400. The form provides information and instructions to employees of self-insured employers in case of an injury or development of an occupational disease.


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Workers' Compensation Employer's Quarterly Report

You must fill out this form quarterly even if you had no workers. These forms are mailed out quarterly to all employers. For instructions on how to complete the Quarterly Report, please refer to F212-239-000 which is available on the internet. This file on the internet is a sample only. Online sample is not available.

Temporary Services Guide to Workers' Compensation Insurance

Used by L&I to assign industrial insurance classifications for workers of temporary help agencies. The first file is a PDF of the Temporary Services Guide to Workers' Compensation Insurance. The second file is a 2003 Excel file. This file is a cross match of non temporary help classifications and the temporary help risk classification associated with that risk class. The third file is a 2003 Excel file. This is a reverse look up for temporary help risk classification and the non temporary classes associated with a temporary help class. File contains an instructions worksheet for the reverse look up worksheet.

International Travel for Work

This fact sheet is for employees of Washington state employers who travel internationally for work. It describes what to do in case of a work-related injury or infectious disease while working abroad. This includes instructions on how to file a workers' compensation claim.

Provider Account Application - Independent Medical Examiner (IME)

In order to do independent medical exams a provider must obtain a provider account number with L&I. This packet includes the application and agreement with instructions, IME Provider Exam sites form (F245-047-000) and Request for Taxpayer ID and Certification - Form W-9 (F248-036-000) (10 pages). If you have questions, please email balk235@lni.wa.gov or call 360-902-6815.

Functional Recovery Interventions Tracking Sheet

Tracking sheet: Provides instructions for providers to track functional recovery interventions (FRI). If a patient has a "positive" functional recovery questionnaire they may be at higher risk for prolonged disability. FRI can help patients  with positive recovery from work related injuries.

CMS 1500 Billing Manual

This manual provides detailed instructions for providers on how to the bill the department using the CMS 1500.

Home Health Services Billing Manual

This billing manual provides instructions to home health providers on how to bill the department.

Hospital Services Billing Manual

This manual provides billing instructions for those billing hospital services to the department.

Pharmacy Billing Manual

This billing manual provides detailed instructions for pharmacies on the correct way to the bill the department for services provided to injured workers.

Asbestos Abatement Project Notice of Intent and L&I DOSH Asbestos Program

Notice is not required for any asbestos project involving less than forty-eight (48) square feet of surface area, or less than ten (10) linear feet of pipe unless the surface area of the pipe is greater than forty-eight (48) square feet. Get instructions to complete the form.

Application for Specialty Electrician Certificate

Application and instructions for the specialty electrician certificate for 03A, 06B, 07A, 07B, 07C, 07D, 07E and 10. Eligibility granted through modified supervision requirements of RCW 19.28.191(1)(g)(ii)

Class B Labels: What You Should Know

Fact Sheet: Explains Class B label electrical work, scope and limitations, and provides general instructions for using Class B labels.

Application for Insignia Conversion Vendor/Medical Units

Used to apply for an official insignia for conversion vendor or medical unit factory-assembled structures. See sample form for instructions about how to fill out the form correctly.

Filing Suit Against an Electrical Contractor

Instructions for filing suit against an electrical contractor

Application for Electrician Examination

Application and instructions for a Washington State electrician's certificate examination.

Certified Project Payroll

There are instructions in one PDF file, and a blank form that may be printed in the other PDF. The word document is saved in Microsoft 2003 format and is a fillable word form.

Crime Victims Direct Entry Billing Manual
Instructions for completing a Direct Entry bill to submit to the Crime Victims Compensation Program. Direct entry allows you to submit or adjust bills using a free online billing form through Provider Express Billing (PEB).

Annual Supplemental Surety Information

Used by self-insured employers to assist in fulfilling surety requirements.

General Provider Billing Manual

General billing information for those providers that bill the department.

Self-Insurance Electronic Data Reporting System (SIEDRS): Enrollment Package 2.0

Book: Explains the technical requirements for participating in SIEDRS, the Self-Insurance Electronic Data Reporting System.


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